ShortCuts-This Week in the Journals

May 12, 2008

Commentary by Cara Litvin MD, Executive Editor, Clinical Correlations

Making headlines this week was a study published in JAMA analyzing prospective data from over 100,000 female participants in the Nurses’ Health Study for 22 years of follow-up. 64% of deaths among current smokers and 28% of deaths among former smokers were attributable to cigarette smoking. However, an encouraging 13% reduction in all cause mortality was seen within the first 5 years of quitting smoking, and after 20 years, the excess risk decreased to the level of a non-smoker. This study yet again confirms that stopping smoking is the single most important thing a smoker can do for their health.

So how do we help our patients stop smoking? This week’s JAMA also contains a commentary summarizing a new clinical practice guideline for treating tobacco use and dependence released by the US Public Health Service. The guideline incorporates evidence-based recommendations to provide a blueprint to clinicians on effective smoking cessation efforts. Brief interventions are emphasized, and counseling, including telephone counseling, is encouraged. The summary also offers evidence for smoking cessation medication. Buproprion and varenicline (Chantix), as well as nicotine replacement medications (gum, patch, nasal spray, lozenge) are all considered first line treatments. Finally, the guideline recognizes that, in addition to the patient and the physician, coordinated interventions within the entire health care system, including the insurer, health care administrator and purchaser are integral to the success of smoking cessation efforts.

In the Lancet this week is a meta-analysis that corroborates the use of carotid artery auscultation as part of the physical exam. In the analysis, which includes 22 studies totaling over 17000 patients with a median follow up of 4 years, rates of myocardial infarction and cardiovascular death were higher in patients with carotid bruits compared to those without, suggesting that aggressive risk modification might be beneficial for patients with carotid bruits found on exam. It’s important to note that the USPSTF recommends against routine screening for routine carotid bruits, and that finding a carotid bruit has only weak predictive accuracy for cerebrovascular events.

The American Psychiatric Association annual meeting was held this week, and mental health amongst veterans was a major concern. At the meeting, Thomas Insel MD, the director of the NIMH, made a chilling warning that suicide amongst vets may outweigh combat deaths. His comments come on the heels of a recent RAND corporation study published in April reporting that nearly a fifth of service members returning from Iraq or Afghanistan report symptoms of PTSD or major depression. Even more concerning, only 53% of those veterans sought treatment, and half of those treated received “minimally adequate treatment.”

And for us internists who are more accustomed to taking care of older patients, the NY Times published an interesting article this week describing “slow medicine,” a concept becoming increasingly available at nursing homes, which, like hospice, emphasizes the idea of comfort care and attempts to minimize emergency room visits and hospitalizations for those of advanced age. The economic burden of providing aggressive medical treatment at the end of life is discussed, and, not surprisingly, the article sites NYU Medical Center as one of the big spenders, paying about $105,000 on an elderly person with many chronic conditions in the last two years of life. On a similar note, in the blogosphere this week, a physician-blogger proposed that every nursing home patient automatically be considered DNR. Jumping one step further, he then suggested that Medicare should create a procedure code for obtaining a DNR order and reimburse a physician for making a patient DNR. Some enticing ideas for proponents of slow medicine…

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